<?php include ('includes/header.php');?>
<?php include ('includes/db_connect.php');?>
<?php
$sqlCategories = "SELECT * FROM categories";
$queryCategories = mysql_query($sqlCategories);
?>

<div class="row">
  <div class="col-lg-12">
    <h1 class="page-header bg-primary text-center" style="text-shadow: 2px 2px 3px black; font-family:optimum">New GER</h1>
  </div>
  <!-- /.col-lg-12 -->
</div>
<!-- /.row -->
<div class="row">
  <div class="col-lg-12">
    <div class="panel panel-default">
      <div class="panel-body">
        <div class="row">
          <div class="col-lg-12">
            <form action="complaints_act.php?act=1" method="POST" role="form" enctype="multipart/form-data">


              <div class="row">
                <div class="col-xs-9 col-sm-9 col-md-9 col-lg-9">
                  <div class="form-group">
                    <label for="category_id">Guest Name</label>
                    <input type="text" class="form-control" id="guest_name" name="guest_name" placeholder="Guest Title & Name">
                  </div>
                </div>
                <div class="col-xs-3 col-sm-3 col-md-3 col-lg-3">
                  <div class="form-group">
                    <label for="category_id">Villa Number</label>
                    <input type="text" class="form-control" id="villa_no" name="villa_no" placeholder="Number Only">
                  </div>
                </div>
              </div>
              <div class="row">
                <div class="col-xs-4 col-sm-4 col-md-4 col-lg-4">
                  <div class="form-group">
                    <label for="complaint_title">Date & Time Complaint</label>
                    <div class="input-group date" id="date_complaint">
                      <input type="text" name="date_complaint" class="form-control" data-date-format="YYYY-MM-DD hh:mm" placeholder="YYYY-MM-DD hh:mm"/>
                      <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span>
                    </span>
                  </div>
                </div>
              </div>
              <div class="col-xs-4 col-sm-4 col-md-4 col-lg-4">
                <div class="form-group">
                  <label for="category_id">Check In date</label>
                  <div class="input-group date" id="ci_date">
                    <input type="text" name="ci_date" class="form-control" data-date-format="YYYY-MM-DD" placeholder="YYYY-MM-DD"/>
                    <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span>
                  </span>
                </div>
              </div>
            </div>
            <div class="col-xs-4 col-sm-4 col-md-4 col-lg-4">
              <div class="form-group">
                <label for="category_id">Check Out Date</label>
                <div class="input-group date" id="co_date">
                  <input type="text" name="co_date" class="form-control" data-date-format="YYYY-MM-DD" placeholder="YYYY-MM-DD"/>
                  <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span>
                </span>
              </div>
            </div>
          </div>
        </div>
        <div class="row">
          <div class="col-xs-6 col-sm-6 col-md-6 col-lg-6">
            <div class="form-group">
              <label for="source">Guest Email</label>
              <input type="text" class="form-control" id="guest_email" name="guest_email" placeholder="Guest Email">
            </div>
          </div>
          <div class="col-xs-4 col-sm-4 col-md-4 col-lg-4">
            <div class="form-group">
              <label for="source">Source</label>
              <input type="text" class="form-control" id="source" name="source" placeholder="Reservation Source (FIT/Agent)">
            </div>
          </div>
          <div class="col-xs-2 col-sm-2 col-md-2 col-lg-2">
            <div class="form-group">
              <label for="nationality">Nationality</label>
              <input type="hidden" id="nationality_temp" name="nationality_temp">
              <select class="form-control" id="nationality" name="nationality">
                <option value="" selected>select country</option>
                <option value="--">none</option>
                <option value="AF" data-nat="AF - Afghanistan">AF - Afghanistan</option>
                <option value="AL" data-nat="AL - Albania">AL - Albania</option>
                <option value="DZ" data-nat="DZ - Algeria">DZ - Algeria</option>
                <option value="AS" data-nat="AS - American Samoa">AS - American Samoa</option>
                <option value="AD" data-nat="AD - Andorra">AD - Andorra</option>
                <option value="AO" data-nat="AO - Angola">AO - Angola</option>
                <option value="AI" data-nat="AI - Anguilla">AI - Anguilla</option>
                <option value="AQ" data-nat="AQ - Antarctica">AQ - Antarctica</option>
                <option value="AG" data-nat="AG - Antigua and Barbuda">AG - Antigua and Barbuda</option>
                <option value="AR" data-nat="AR - Argentina">AR - Argentina</option>
                <option value="AM" data-nat="AM - Armenia">AM - Armenia</option>
                <option value="AW" data-nat="AW - Aruba">AW - Aruba</option>
                <option value="AU" data-nat="AU - Australia">AU - Australia</option>
                <option value="AT" data-nat="AT - Austria">AT - Austria</option>
                <option value="AZ" data-nat="AZ - Azerbaijan">AZ - Azerbaijan</option>
                <option value="BS" data-nat="BS - Bahamas">BS - Bahamas</option>
                <option value="BH" data-nat="BH - Bahrain">BH - Bahrain</option>
                <option value="BD" data-nat="BD - Bangladesh">BD - Bangladesh</option>
                <option value="BB" data-nat="BB - Barbados">BB - Barbados</option>
                <option value="BY" data-nat="BY - Belarus">BY - Belarus</option>
                <option value="BE" data-nat="BE - Belgium">BE - Belgium</option>
                <option value="BZ" data-nat="BZ - Belize">BZ - Belize</option>
                <option value="BJ" data-nat="BJ - Benin">BJ - Benin</option>
                <option value="BM" data-nat="BM - Bermuda">BM - Bermuda</option>
                <option value="BT" data-nat="BT - Bhutan">BT - Bhutan</option>
                <option value="BO" data-nat="BO - Bolivia">BO - Bolivia</option>
                <option value="BA" data-nat="BA - Bosnia and Herzegowina">BA - Bosnia and Herzegowina</option>
                <option value="BW" data-nat="BW - Botswana">BW - Botswana</option>
                <option value="BV" data-nat="BV - Bouvet Island">BV - Bouvet Island</option>
                <option value="BR" data-nat="BR - Brazil">BR - Brazil</option>
                <option value="IO" data-nat="IO - British Indian Ocean Territory">IO - British Indian Ocean Territory</option>
                <option value="BN" data-nat="BN - Brunei Darussalam">BN - Brunei Darussalam</option>
                <option value="BG" data-nat="BG - Bulgaria">BG - Bulgaria</option>
                <option value="BF" data-nat="BF - Burkina Faso">BF - Burkina Faso</option>
                <option value="BI" data-nat="BI - Burundi">BI - Burundi</option>
                <option value="KH" data-nat="KH - Cambodia">KH - Cambodia</option>
                <option value="CM" data-nat="CM - Cameroon">CM - Cameroon</option>
                <option value="CA" data-nat="CA - Canada">CA - Canada</option>
                <option value="CV" data-nat="CV - Cape Verde">CV - Cape Verde</option>
                <option value="KY" data-nat="KY - Cayman Islands">KY - Cayman Islands</option>
                <option value="CF" data-nat="CF - Central African Republic">CF - Central African Republic</option>
                <option value="TD" data-nat="TD - Chad">TD - Chad</option>
                <option value="CL" data-nat="CL - Chile">CL - Chile</option>
                <option value="CN" data-nat="CN - China">CN - China</option>
                <option value="CX" data-nat="CX - Christmas Island">CX - Christmas Island</option>
                <option value="CC" data-nat="CC - Cocos (Keeling) Islands">CC - Cocos (Keeling) Islands</option>
                <option value="CO" data-nat="CO - Colombia">CO - Colombia</option>
                <option value="KM" data-nat="KM - Comoros">KM - Comoros</option>
                <option value="CG" data-nat="CG - Congo">CG - Congo</option>
                <option value="CD" data-nat="CD - Congo, the Democratic Republic of the">CD - Congo, the Democratic Republic of the</option>
                <option value="CK" data-nat="CK - Cook Islands">CK - Cook Islands</option>
                <option value="CR" data-nat="CR - Costa Rica">CR - Costa Rica</option>
                <option value="CI" data-nat="CI - Cote d'Ivoire">CI - Cote d'Ivoire</option>
                <option value="HR" data-nat="HR - Croatia (Hrvatska)">HR - Croatia (Hrvatska)</option>
                <option value="CU" data-nat="CU - Cuba">CU - Cuba</option>
                <option value="CY" data-nat="CY - Cyprus">CY - Cyprus</option>
                <option value="CZ" data-nat="CZ - Czech Republic">CZ - Czech Republic</option>
                <option value="DK" data-nat="DK - Denmark">DK - Denmark</option>
                <option value="DJ" data-nat="DJ - Djibouti">DJ - Djibouti</option>
                <option value="DM" data-nat="DM - Dominica">DM - Dominica</option>
                <option value="DO" data-nat="DO - Dominican Republic">DO - Dominican Republic</option>
                <option value="TP" data-nat="TP - East Timor">TP - East Timor</option>
                <option value="EC" data-nat="EC - Ecuador">EC - Ecuador</option>
                <option value="EG" data-nat="EG - Egypt">EG - Egypt</option>
                <option value="SV" data-nat="SV - El Salvador">SV - El Salvador</option>
                <option value="GQ" data-nat="GQ - Equatorial Guinea">GQ - Equatorial Guinea</option>
                <option value="ER" data-nat="ER - Eritrea">ER - Eritrea</option>
                <option value="EE" data-nat="EE - Estonia">EE - Estonia</option>
                <option value="ET" data-nat="ET - Ethiopia">ET - Ethiopia</option>
                <option value="FK" data-nat="FK - Falkland Islands (Malvinas)">FK - Falkland Islands (Malvinas)</option>
                <option value="FO" data-nat="FO - Faroe Islands">FO - Faroe Islands</option>
                <option value="FJ" data-nat="FJ - Fiji">FJ - Fiji</option>
                <option value="FI" data-nat="FI - Finland">FI - Finland</option>
                <option value="FR" data-nat="FR - France">FR - France</option>
                <option value="FX" data-nat="FX - France, Metropolitan">FX - France, Metropolitan</option>
                <option value="GF" data-nat="GF - French Guiana">GF - French Guiana</option>
                <option value="PF" data-nat="PF - French Polynesia">PF - French Polynesia</option>
                <option value="TF" data-nat="TF - French Southern Territories">TF - French Southern Territories</option>
                <option value="GA" data-nat="GA - Gabon">GA - Gabon</option>
                <option value="GM" data-nat="GM - Gambia">GM - Gambia</option>
                <option value="GE" data-nat="GE - Georgia">GE - Georgia</option>
                <option value="DE" data-nat="DE - Germany">DE - Germany</option>
                <option value="GH" data-nat="GH - Ghana">GH - Ghana</option>
                <option value="GI" data-nat="GI - Gibraltar">GI - Gibraltar</option>
                <option value="GR" data-nat="GR - Greece">GR - Greece</option>
                <option value="GL" data-nat="GL - Greenland">GL - Greenland</option>
                <option value="GD" data-nat="GD - Grenada">GD - Grenada</option>
                <option value="GP" data-nat="GP - Guadeloupe">GP - Guadeloupe</option>
                <option value="GU" data-nat="GU - Guam">GU - Guam</option>
                <option value="GT" data-nat="GT - Guatemala">GT - Guatemala</option>
                <option value="GN" data-nat="GN - Guinea">GN - Guinea</option>
                <option value="GW" data-nat="GW - Guinea-Bissau">GW - Guinea-Bissau</option>
                <option value="GY" data-nat="GY - Guyana">GY - Guyana</option>
                <option value="HT" data-nat="HT - Haiti">HT - Haiti</option>
                <option value="HM" data-nat="HM - Heard and Mc Donald Islands">HM - Heard and Mc Donald Islands</option>
                <option value="VA" data-nat="VA - Holy See (Vatican City State)">VA - Holy See (Vatican City State)</option>
                <option value="HN" data-nat="HN - Honduras">HN - Honduras</option>
                <option value="HK" data-nat="HK - Hong Kong">HK - Hong Kong</option>
                <option value="HU" data-nat="HU - Hungary">HU - Hungary</option>
                <option value="IS" data-nat="IS - Iceland">IS - Iceland</option>
                <option value="IN" data-nat="IN - India">IN - India</option>
                <option value="ID" data-nat="ID - Indonesia">ID - Indonesia</option>
                <option value="IR" data-nat="IR - Iran (Islamic Republic of)">IR - Iran (Islamic Republic of)</option>
                <option value="IQ" data-nat="IQ - Iraq">IQ - Iraq</option>
                <option value="IE" data-nat="IE - Ireland">IE - Ireland</option>
                <option value="IL" data-nat="IL - Israel">IL - Israel</option>
                <option value="IT" data-nat="IT - Italy">IT - Italy</option>
                <option value="JM" data-nat="JM - Jamaica">JM - Jamaica</option>
                <option value="JP" data-nat="JP - Japan">JP - Japan</option>
                <option value="JO" data-nat="JO - Jordan">JO - Jordan</option>
                <option value="KZ" data-nat="KZ - Kazakhstan">KZ - Kazakhstan</option>
                <option value="KE" data-nat="KE - Kenya">KE - Kenya</option>
                <option value="KI" data-nat="KI - Kiribati">KI - Kiribati</option>
                <option value="KP" data-nat="KP - Korea, Democratic People's Republic of">KP - Korea, Democratic People's Republic of</option>
                <option value="KR" data-nat="KR - Korea, Republic of">KR - Korea, Republic of</option>
                <option value="KW" data-nat="KW - Kuwait">KW - Kuwait</option>
                <option value="KG" data-nat="KG - Kyrgyzstan">KG - Kyrgyzstan</option>
                <option value="LA" data-nat="LA - Lao People's Democratic Republic">LA - Lao People's Democratic Republic</option>
                <option value="LV" data-nat="LV - Latvia">LV - Latvia</option>
                <option value="LB" data-nat="LB - Lebanon">LB - Lebanon</option>
                <option value="LS" data-nat="LS - Lesotho">LS - Lesotho</option>
                <option value="LR" data-nat="LR - Liberia">LR - Liberia</option>
                <option value="LY" data-nat="LY - Libyan Arab Jamahiriya">LY - Libyan Arab Jamahiriya</option>
                <option value="LI" data-nat="LI - Liechtenstein">LI - Liechtenstein</option>
                <option value="LT" data-nat="LT - Lithuania">LT - Lithuania</option>
                <option value="LU" data-nat="LU - Luxembourg">LU - Luxembourg</option>
                <option value="MO" data-nat="MO - Macau">MO - Macau</option>
                <option value="MK" data-nat="MK - Macedonia, The Former Yugoslav Republic of">MK - Macedonia, The Former Yugoslav Republic of</option>
                <option value="MG" data-nat="MG - Madagascar">MG - Madagascar</option>
                <option value="MW" data-nat="MW - Malawi">MW - Malawi</option>
                <option value="MY" data-nat="MY - Malaysia">MY - Malaysia</option>
                <option value="MV" data-nat="MV - Maldives">MV - Maldives</option>
                <option value="ML" data-nat="ML - Mali">ML - Mali</option>
                <option value="MT" data-nat="MT - Malta">MT - Malta</option>
                <option value="MH" data-nat="MH - Marshall Islands">MH - Marshall Islands</option>
                <option value="MQ" data-nat="MQ - Martinique">MQ - Martinique</option>
                <option value="MR" data-nat="MR - Mauritania">MR - Mauritania</option>
                <option value="MU" data-nat="MU - Mauritius">MU - Mauritius</option>
                <option value="YT" data-nat="YT - Mayotte">YT - Mayotte</option>
                <option value="MX" data-nat="MX - Mexico">MX - Mexico</option>
                <option value="FM" data-nat="FM - Micronesia, Federated States of">FM - Micronesia, Federated States of</option>
                <option value="MD" data-nat="MD - Moldova, Republic of">MD - Moldova, Republic of</option>
                <option value="MC" data-nat="MC - Monaco">MC - Monaco</option>
                <option value="MN" data-nat="MN - Mongolia">MN - Mongolia</option>
                <option value="MS" data-nat="MS - Montserrat">MS - Montserrat</option>
                <option value="MA" data-nat="MA - Morocco">MA - Morocco</option>
                <option value="MZ" data-nat="MZ - Mozambique">MZ - Mozambique</option>
                <option value="MM" data-nat="MM - Myanmar">MM - Myanmar</option>
                <option value="NA" data-nat="NA - Namibia">NA - Namibia</option>
                <option value="NR" data-nat="NR - Nauru">NR - Nauru</option>
                <option value="NP" data-nat="NP - Nepal">NP - Nepal</option>
                <option value="NL" data-nat="NL - Netherlands">NL - Netherlands</option>
                <option value="AN" data-nat="AN - Netherlands Antilles">AN - Netherlands Antilles</option>
                <option value="NC" data-nat="NC - New Caledonia">NC - New Caledonia</option>
                <option value="NZ" data-nat="NZ - New Zealand">NZ - New Zealand</option>
                <option value="NI" data-nat="NI - Nicaragua">NI - Nicaragua</option>
                <option value="NE" data-nat="NE - Niger">NE - Niger</option>
                <option value="NG" data-nat="NG - Nigeria">NG - Nigeria</option>
                <option value="NU" data-nat="NU - Niue">NU - Niue</option>
                <option value="NF" data-nat="NF - Norfolk Island">NF - Norfolk Island</option>
                <option value="MP" data-nat="MP - Northern Mariana Islands">MP - Northern Mariana Islands</option>
                <option value="NO" data-nat="NO - Norway">NO - Norway</option>
                <option value="OM" data-nat="OM - Oman">OM - Oman</option>
                <option value="PK" data-nat="PK - Pakistan">PK - Pakistan</option>
                <option value="PW" data-nat="PW - Palau">PW - Palau</option>
                <option value="PA" data-nat="PA - Panama">PA - Panama</option>
                <option value="PG" data-nat="PG - Papua New Guinea">PG - Papua New Guinea</option>
                <option value="PY" data-nat="PY - Paraguay">PY - Paraguay</option>
                <option value="PE" data-nat="PE - Peru">PE - Peru</option>
                <option value="PH" data-nat="PH - Philippines">PH - Philippines</option>
                <option value="PN" data-nat="PN - Pitcairn">PN - Pitcairn</option>
                <option value="PL" data-nat="PL - Poland">PL - Poland</option>
                <option value="PT" data-nat="PT - Portugal">PT - Portugal</option>
                <option value="PR" data-nat="PR - Puerto Rico">PR - Puerto Rico</option>
                <option value="QA" data-nat="QA - Qatar">QA - Qatar</option>
                <option value="RE" data-nat="RE - Reunion">RE - Reunion</option>
                <option value="RO" data-nat="RO - Romania">RO - Romania</option>
                <option value="RU" data-nat="RU - Russian Federation">RU - Russian Federation</option>
                <option value="RW" data-nat="RW - Rwanda">RW - Rwanda</option>
                <option value="KN" data-nat="KN - Saint Kitts and Nevis">KN - Saint Kitts and Nevis</option>
                <option value="LC" data-nat="LC - Saint LUCIA">LC - Saint LUCIA</option>
                <option value="VC" data-nat="VC - Saint Vincent and the Grenadines">VC - Saint Vincent and the Grenadines</option>
                <option value="WS" data-nat="WS - Samoa">WS - Samoa</option>
                <option value="SM" data-nat="SM - San Marino">SM - San Marino</option>
                <option value="ST" data-nat="ST - Sao Tome and Principe">ST - Sao Tome and Principe</option>
                <option value="SA" data-nat="SA - Saudi Arabia">SA - Saudi Arabia</option>
                <option value="SN" data-nat="SN - Senegal">SN - Senegal</option>
                <option value="SC" data-nat="SC - Seychelles">SC - Seychelles</option>
                <option value="SL" data-nat="SL - Sierra Leone">SL - Sierra Leone</option>
                <option value="SG" data-nat="SG - Singapore">SG - Singapore</option>
                <option value="SK" data-nat="SK - Slovakia (Slovak Republic)">SK - Slovakia (Slovak Republic)</option>
                <option value="SI" data-nat="SI - Slovenia">SI - Slovenia</option>
                <option value="SB" data-nat="SB - Solomon Islands">SB - Solomon Islands</option>
                <option value="SO" data-nat="SO - Somalia">SO - Somalia</option>
                <option value="ZA" data-nat="ZA - South Africa">ZA - South Africa</option>
                <option value="GS" data-nat="GS - South Georgia and the South Sandwich Islands">GS - South Georgia and the South Sandwich Islands</option>
                <option value="ES" data-nat="ES - Spain">ES - Spain</option>
                <option value="LK" data-nat="LK - Sri Lanka">LK - Sri Lanka</option>
                <option value="SH" data-nat="SH - St. Helena">SH - St. Helena</option>
                <option value="PM" data-nat="PM - St. Pierre and Miquelon">PM - St. Pierre and Miquelon</option>
                <option value="SD" data-nat="SD - Sudan">SD - Sudan</option>
                <option value="SR" data-nat="SR - Suriname">SR - Suriname</option>
                <option value="SJ" data-nat="SJ - Svalbard and Jan Mayen Islands">SJ - Svalbard and Jan Mayen Islands</option>
                <option value="SZ" data-nat="SZ - Swaziland">SZ - Swaziland</option>
                <option value="SE" data-nat="SE - Sweden">SE - Sweden</option>
                <option value="CH" data-nat="CH - Switzerland">CH - Switzerland</option>
                <option value="SY" data-nat="SY - Syrian Arab Republic">SY - Syrian Arab Republic</option>
                <option value="TW" data-nat="TW - Taiwan, Province of China">TW - Taiwan, Province of China</option>
                <option value="TJ" data-nat="TJ - Tajikistan">TJ - Tajikistan</option>
                <option value="TZ" data-nat="TZ - Tanzania, United Republic of">TZ - Tanzania, United Republic of</option>
                <option value="TH" data-nat="TH - Thailand">TH - Thailand</option>
                <option value="TG" data-nat="TG - Togo">TG - Togo</option>
                <option value="TK" data-nat="TK - Tokelau">TK - Tokelau</option>
                <option value="TO" data-nat="TO - Tonga">TO - Tonga</option>
                <option value="TT" data-nat="TT - Trinidad and Tobago">TT - Trinidad and Tobago</option>
                <option value="TN" data-nat="TN - Tunisia">TN - Tunisia</option>
                <option value="TR" data-nat="TR - Turkey">TR - Turkey</option>
                <option value="TM" data-nat="TM - Turkmenistan">TM - Turkmenistan</option>
                <option value="TC" data-nat="TC - Turks and Caicos Islands">TC - Turks and Caicos Islands</option>
                <option value="TV" data-nat="TV - Tuvalu">TV - Tuvalu</option>
                <option value="UG" data-nat="UG - Uganda">UG - Uganda</option>
                <option value="UA" data-nat="UA - Ukraine">UA - Ukraine</option>
                <option value="AE" data-nat="AE - United Arab Emirates">AE - United Arab Emirates</option>
                <option value="GB" data-nat="GB - United Kingdom">GB - United Kingdom</option>
                <option value="US" data-nat="US - United States">US - United States</option>
                <option value="UM" data-nat="UM - United States Minor Outlying Islands">UM - United States Minor Outlying Islands</option>
                <option value="UY" data-nat="UY - Uruguay">UY - Uruguay</option>
                <option value="UZ" data-nat="UZ - Uzbekistan">UZ - Uzbekistan</option>
                <option value="VU" data-nat="VU - Vanuatu">VU - Vanuatu</option>
                <option value="VE" data-nat="VE - Venezuela">VE - Venezuela</option>
                <option value="VN" data-nat="VN - Viet Nam">VN - Viet Nam</option>
                <option value="VG" data-nat="VG - Virgin Islands (British)">VG - Virgin Islands (British)</option>
                <option value="VI" data-nat="VI - Virgin Islands (U.S.)">VI - Virgin Islands (U.S.)</option>
                <option value="WF" data-nat="WF - Wallis and Futuna Islands">WF - Wallis and Futuna Islands</option>
                <option value="EH" data-nat="EH - Western Sahara">EH - Western Sahara</option>
                <option value="YE" data-nat="YE - Yemen">YE - Yemen</option>
                <option value="YU" data-nat="YU - Yugoslavia">YU - Yugoslavia</option>
                <option value="ZM" data-nat="ZM - Zambia">ZM - Zambia</option>
                <option value="ZW" data-nat="ZW - Zimbabwe">ZW - Zimbabwe</option>
              </select>
            </div>
          </div>
        </div>

        <div class="row">
          <div class="col-xs-7 col-sm-7 col-md-7 col-lg-7">
            <div class="form-group">
              <label for="complaint_title">Issue</label>
              <input type="text" class="form-control" id="complaint_title" name="complaint_title" placeholder="Issue">
            </div>
          </div>
          <div class="col-xs-5 col-sm-5 col-md-5 col-lg-5">
            <div class="form-group">
              <label for="category_id">Category</label>
              <select name="category_id" id="category_id" class="form-control">
                <?php while ($row = mysql_fetch_array($queryCategories)) { ?>
                <option value="<?php echo $row['id'] ?>"><?php echo $row['name']; ?></option>
                <?php } ?>
              </select>
            </div>
          </div>
        </div>

        <div class="form-group">
          <label for="description">Description</label>
          <textarea class="form-control" id="description" name="description" rows="10"></textarea>
        </div>

        <div class="form-group">
          <label for="recovery">Recovery Action</label>
          <textarea class="form-control" id="recovery" name="recovery" rows="10"></textarea>
        </div>

        <div class="form-group">
          <label for="follow_up">Followed Up By</label>
          <input type="text" class="form-control" id="follow_up" name="follow_up" placeholder="Followed Up By">

          <div class="form-group">
            <label for="further_follow_up">Further follow Up</label>
            <textarea class="form-control" id="further_follow_up" name="further_follow_up" rows="3" placeholder="Put -NA- if further follow up are not necessary"></textarea>
          </div>
        </div>

        <div class="form-group">
          <label for="compensation">Compensation</label>
          <input type="text" class="form-control" id="compensation" name="compensation" placeholder="Compensation">
        </div>

        <div class="form-group">
          <label for="price">Cost</label>
          <input type="text" class="form-control" id="price" name="price" placeholder="Total cost - Number only - in IDR">
        </div>

        <div class="form-group">
          <label for="created_by">Created By</label>
          <input type="text" class="form-control" id="created_by" name="created_by" placeholder="Created By">
        </div>


        <button type="submit" class="btn btn-danger">Submit</button>
      </form>
    </div>
    <!-- /.col-lg-6 (nested) -->
  </div>
  <!-- /.row (nested) -->
</div>
<!-- /.panel-body -->
</div>
<!-- /.panel -->
</div>
<!-- /.col-lg-12 -->
</div>
<!-- /.row -->

<?php include ('includes/footer.php');?>